Stacy McLaughlin, RN, MSN. Director of Quality & Performance Improvement

Transcription

1 Stacy McLaughlin, RN, MSN Director of Quality & Performance Improvement

2 25-bed CAH 21 beds: acute / observation / swingbed 4 bed ICU ED volumes: 14,400 encounters/year 5 Clinics: Rural Health / Primary Care / Surgical Care Home Care services After Hours Urgent Care Various Outpatient services Organizational & Administrative Changes

3 Creating a foundation of our overall Quality structure Networking with our CAH collaborative organization Increasing transparency of data outcomes Increasing employees knowledge & involvement in Quality & PI processes

4

5

6

7

8

9

10

11 Departmental QI Presentations

12 ICU ICU Nurse Manager

13 PLAN THE IMPROVEMENT Problem statement: Monthly chart audits indicated a low compliance with reassessment of pain after intervention. Causes of variation? Nursing documentation lacking Change of shift (Meds given & no follow-up by next shift) Handoff communication Routine assessment documentation does not meet time criteria for follow-up

14 PLAN THE IMPROVEMENT Why do we want to improve? To ensure patient comfort Improve patient satisfaction Promote patient involvement in care Stakeholders? Patients, staff, providers, organization How will this be measured? Jan-Oct: Director Audits Pain Reassessment Audit Tool To be discussed via Measure Roadmap

15 DO THE IMPROVEMENT Implement the improvement & Test the improvement action Discussion in dept staff meetings Documentation case studies: Skills days Education: Patient Centered culture Development of monitoring tool Staff training on concurrent audit process

16 CHECK THE RESULTS Collect data to determine if the desired outcomes are being achieved

17 CHECK THE RESULTS Collect data to determine if the desired outcomes are being achieved

18 ACT TO HOLD GAINS & CONTINUE TO IMPROVE Ask the question, How can this process be improved further? Continuing data collection process involving frontline staff in performing audits for more immediate change 3 random chart audit assignments to 3 nurses every 2 weeks (Capturing all patient admissions within each 2 week period) Increased sampling: 100% of ICU patient population

19 THE MEASURE ROADMAP Strategic Objective: To ensure high quality of care through pain control Frequency of Update: Quarterly Measure: Percentage of timely reassessment of pain Measurement Intent: Appropiate reassessment of pain following an intervention Units of Measure: Reassessments compared to total number of medications given. Notes: Jan-Oct 2012 data obtained from Director by doing random chart audits. Scheduled medications are not included in the audit. Excluded patients not receiving any pain medications during their hospital stay. Excluded any non-pain PRN medications for this audit. November data reflects the change in process of collecting information through new audit tool. Measurement/Information: 3-4 pts to 6 Nurses per month.allows us to assess 100% of patients who have received pain medication Data Elements and Sources: Through Chartlink EMAR Source For and Approach to Setting Targets: Goal of 92%. To formalize from our baseline data Accountability for Meeting Target: Staff involved in chart audits. Staff buy-in to process. ICU Director assigns audits to staff. Oversight and compiling of date by Director to report to PI Tracking/Reporting Responsibility: ICU Director reports quarterly to QI Committee 2013 Jan Feb 84% 85% March 83% April 77% May 88% June July Aug Sept Oct Nov Dec Target Baseline Q1 Q2 Q3 >92% 51% 2012 year statistic 84% Q4

20 PI: PHASE II QUALITY BOARDS

21

22 Guidance on focus needs Ownership & engagement towards change

23 Continued focus on our culture Strengthening our foundation of key Quality components

24 Alignment of quality initiatives & goals top down Mission - Vision Organizational & strategic objectives Specific department & employee level goals Transparency of data Relate it to patient centeredness - not just a score Make a case for business survival Staff engagement Communicate, Communicate, Communicate! Thank you!